What is the treatment for a 4-year-old with diarrhea?

From the Guidelines

For a 4-year-old with diarrhea, the primary treatment is oral rehydration therapy using an oral rehydration solution (ORS) to prevent dehydration, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. Give small amounts frequently, aiming for 1-2 ounces (30-60 ml) every 15-30 minutes. Continue regular feeding as tolerated, avoiding sugary drinks, dairy products, and fatty foods which may worsen symptoms. Probiotics like Lactobacillus GG or Saccharomyces boulardii may help reduce the duration of diarrhea; typical dosing is one capsule or 5-10 ml of liquid formulation once or twice daily. Anti-diarrheal medications like loperamide (Imodium) should NOT be given to young children as they can cause serious side effects, as stated in the 2017 guidelines 1. Watch for signs of dehydration including decreased urination, dry mouth, no tears when crying, and unusual drowsiness. Ensure good hand hygiene to prevent spread to others. Most childhood diarrhea is caused by viral infections that resolve within 5-7 days. Seek medical attention if the child shows signs of dehydration, has bloody diarrhea, high fever above 102°F (39°C), severe abdominal pain, or if diarrhea persists beyond 7 days. According to the Centers for Disease Control and Prevention, management of acute diarrhea should begin at home with oral rehydration therapy 1. The use of reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy for mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause, as stated in the 2017 guidelines 1. Nasogastric administration of ORS may be considered in infants, children, and adults with moderate dehydration who cannot tolerate oral intake 1. Isotonic intravenous fluids such as lactated Ringer’s and normal saline solution should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy 1. In severe dehydration, intravenous rehydration should be continued until pulse, perfusion, and mental status normalize and the patient awakens, has no risk factors for aspiration, and has no evidence of ileus 1. Once the patient is rehydrated, maintenance fluids should be administered, replacing ongoing losses in stools with ORS until diarrhea and vomiting are resolved 1. Antiemetic agents like ondansetron may be given to facilitate tolerance of oral rehydration in children >4 years of age and in adolescents with acute gastroenteritis associated with vomiting, as recommended in the 2017 guidelines 1. However, the routine use of antiemetic agents for acute gastroenteritis in children <4 years of age or in adults is not recommended 1. Loperamide may be given to immunocompetent adults with acute watery diarrhea, but should be avoided at any age in suspected or proven cases where toxic megacolon may result in inflammatory diarrhea or diarrhea with fever 1. Patients should be advised about medications with the potential to increase the risk of complications from diarrhea, particularly antidiarrheal and antimicrobial agents 1. The safety and efficacy of ORS, in comparison to intravenous rehydration therapy (IVT), was evaluated in a meta-analysis of 17 RCTs involving 1811 patients aged <18 years from high-income and low-income countries, showing no important clinical differences in failure to rehydrate, weight gain at discharge, hyponatremia or hypernatremia, duration of diarrhea, or total fluid intake at 6 or 24 hours between children receiving ORS and IVT 1. Low-osmolarity ORS can be given to all age groups, with any cause of diarrhea, and is safe in the presence of hypernatremia as well as hyponatremia, except when edema is present 1. Some commercially available formulations that can be used as ORS include Pedialyte Liters, CeraLyte, and Enfalac Lytren 1. Popular beverages that should not be used for rehydration include apple juice, Gatorade, and commercial soft drinks 1. Breastfed infants should continue nursing throughout the illness, and children previously receiving a lactose-containing formula can tolerate the same product in most instances 1. Diluted formula does not appear to confer any benefit, and maintenance fluids should be resumed along with an age-appropriate normal diet offered every 3–4 hours 1. Replacement of water, electrolytes, and nutrients lost during diarrhea is essential in the management of diarrhea, and oral rehydration has been shown to be useful in all ages, regardless of the cause 1. Ondansetron can reduce vomiting in children and reduce the need for hospitalization for rehydration, although it may increase stool volume 1. Bismuth subsalicylate is mildly effective, and racecadotril reduces stool volume but is not available in North America 1. Loperamide is a locally acting opioid receptor agonist that decreases the muscular tone and motility of the intestinal wall, and has been shown to be effective in reducing diarrhea in healthy adults, but most of the studies have been focused on travelers to resource-challenged countries and the drug was used in combination with antimicrobial agents 1. Patients with ketonemia may need an initial course of intravenous hydration to enable tolerance of oral rehydration 1. In people with severe dehydration, intravenous rehydration should be continued until pulse, perfusion, and mental status normalize, and the remaining deficit can be replaced by using ORS 1. Infants, children, and adults with mild to moderate dehydration should receive ORS until clinical dehydration is corrected, and maintenance fluids should be administered to replace ongoing losses in stools until diarrhea and vomiting are resolved 1. The 2017 Infectious Diseases Society of America clinical practice guidelines recommend the use of reduced osmolarity ORS as the first-line therapy for mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause 1. The guidelines also recommend that antimotility drugs, such as loperamide, should not be given to children <18 years of age with acute diarrhea, and that antiemetic agents, such as ondansetron, may be given to facilitate tolerance of oral rehydration in children >4 years of age and in adolescents with acute gastroenteritis associated with vomiting 1. Overall, the primary treatment for a 4-year-old with diarrhea is oral rehydration therapy using an oral rehydration solution (ORS) to prevent dehydration, and the use of antiemetic agents and antimotility drugs should be guided by the 2017 Infectious Diseases Society of America clinical practice guidelines 1.

From the FDA Drug Label

Loperamide hydrochloride capsules are indicated for the control and symptomatic relief of acute nonspecific diarrhea in patients 2 years of age and older The treatment for a 4-year-old with diarrhea is loperamide (PO), as it is indicated for the control and symptomatic relief of acute nonspecific diarrhea in patients 2 years of age and older 2.

• Key points:
  • Age: 2 years and older
  • Indication: acute nonspecific diarrhea
  • Drug: loperamide (PO)

From the Research

Treatment for 4-year-old with Diarrhea

• The treatment for a 4-year-old with diarrhea typically involves oral rehydration solutions to compensate for water and electrolyte losses 3.
• Loperamide can be used as an antidiarrheal drug in acute and chronic diarrhea, but its use in children has been discouraged by some organizations due to concerns over safety and efficacy in young children 4.
• A systematic review and meta-analysis found that loperamide was effective in reducing the duration and severity of diarrhea in children, but serious adverse events were reported in children younger than 3 years 4.
• For children older than 3 years with no or minimal dehydration, loperamide may be a useful adjunct to oral rehydration and early refeeding 4.
• Oral rehydration therapy is effective in rehydrating infants with mild to moderate dehydration caused by acute diarrhea, and a single solution can be used for both rehydration and maintenance therapy 5.

Oral Rehydration Solutions

• Oral rehydration solutions typically contain glucose or glucose polymers and sodium, as well as other electrolytes 3.
• A study found that two commonly used oral rehydration solutions, Pedialyte and Infalyte, were effective in rehydrating infants with mild to moderate dehydration 5.
• The use of a single solution for oral rehydration and maintenance therapy may be a useful strategy in the treatment of diarrhea in children 5.

Loperamide Therapy

• Loperamide can be used in combination with antibiotics to treat traveler's diarrhea, and has been shown to decrease the duration of illness and increase the probability of early clinical cure 6.
• However, the use of loperamide alone versus loperamide plus oral rehydration therapy has been found to have equivalent clinical responses in the treatment of traveler's diarrhea 7.